A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?
Prepare for cesarean birth.
Initiate an IV infusion of magnesium sulfate.
Administer antibiotics.
Request the RN to perform a cervical examination.
The Correct Answer is A
Choice A rationale :
Prepare for cesarean birth. The nurse should consider preparing for a cesarean birth as the client is at 39 weeks of gestation and has heavy vaginal bleeding. Heavy vaginal bleeding during pregnancy could indicate an emergency situation such as placental abruption or placenta previa, both of which can be life-threatening for the mother and the baby. In such cases, an emergency cesarean birth might be necessary to ensure the safety of both the client and the baby. Promptly preparing for the procedure will help expedite the process and prevent any delays in providing necessary medical care.
Choice B rationale
Initiate an IV infusion of magnesium sulfate. Magnesium sulfate is not indicated in this situation. Magnesium sulfate is commonly used in obstetrics, particularly in the management of preeclampsia and eclampsia to prevent seizures. However, the client's heavy vaginal bleeding suggests a different issue and magnesium sulfate would not address the underlying cause. Instead, the focus should be on identifying and managing the cause of the bleeding to ensure the best outcome for the client and the baby.
Choice C rationale
Administer antibiotics. Administering antibiotics is not the priority action in this scenario. Heavy vaginal bleeding in a pregnant client requires immediate attention to assess the cause and determine the appropriate course of action. While antibiotics may be necessary in some situations, they are not the first-line treatment for heavy vaginal bleeding during pregnancy. The nurse should focus on providing prompt and appropriate care to address the client's immediate needs.
Choice D rationale
Request the RN to perform a cervical examination. Performing a cervical examination may provide valuable information about the cause of the heavy vaginal bleeding. It can help determine if the bleeding is related to cervical changes, such as cervical dilation or effacement. The findings from the cervical examination, along with other assessments, will aid in making the most appropriate decisions regarding the client's care. However, it is not the only action that the nurse should take. In this critical situation, the nurse must prioritize immediate interventions to ensure the safety and well-being of the client and the baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A (7) rationale: The nurse should not select 7 as the Apgar score because the newborn exhibited several positive signs at 5 minutes after birth, such as a heart rate of 130/min, a lusty cry with tactile stimulation, and flexed extremities, indicating good muscle tone and reflexes.
Choice B (8) rationale: Choice B can be eliminated as the correct answer because the newborn displayed more than just moderate signs of normal adaptation. With a heart rate of 130/min, a lusty cry with tactile stimulation, and flexed extremities, as well as acrocyanosis and a grimace when suctioned, the newborn shows excellent adaptation to extrauterine life.
Choice C (9) rationale: The nurse should select Choice C as the correct answer. At 5 minutes after birth, the newborn's Apgar score would be 9 because it exhibited good overall adaptation with a heart rate of 130/min, a lusty cry with tactile stimulation, flexed extremities, and some acrocyanosis and grimace when suctioned.
Choice D (10) rationale: Choice D (10) should be excluded as the correct answer since the newborn had acrocyanosis and a grimace when suctioned, which indicates some minor difficulty in adapting to the new environment.
Correct Answer is A
Explanation
Choice A:
During the immediate postpartum period, shaking chills can be indicative of an infection or fever. Therefore, the nurse should first assess the client's temperature to identify if there is a fever. This information is crucial for making appropriate clinical decisions and providing necessary interventions.
Choice B:
The reason for not selecting B, and placing the client on seizure precautions, is that shaking chills alone do not necessarily indicate a seizure. Seizure precautions are typically implemented for clients with a history of seizures or those at risk for seizures due to neurological conditions. In this scenario, focusing on the client's temperature is more relevant to address the immediate concern.
Choice C:
The reason for not choosing C, notifying the charge nurse, is that this action might not directly address the client's condition. While involving the charge nurse can be essential for certain situations, it is not the primary intervention required for a client experiencing shaking chills. The nurse should first assess the client and initiate appropriate actions based on their assessment.
Choice D:
The reason for not selecting D, covering the client with warm blankets, is that shaking chills are often associated with fever, which indicates the body is trying to raise its temperature. Providing warm blankets may exacerbate the fever and is not the appropriate initial action. Determining the client's temperature is necessary to guide further interventions effectively.
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